What It’s Like to Work for Doctors Without Borders

Dr. Craig Spencer is the director of Global Health in Emergency Medicine at New York-Presbyterian/Columbia University Medical Center and a physician for Medecins Sans Frontieres (MSF), aka Doctors Without Borders. He has worked in Africa and Southeast Asia as a field epidemiologist, measuring mortality and maternal health in Burundi and child separation in emergencies in South Sudan and the Democratic Republic of Congo. More recently, Spencer organized the Doctors Without Borders response in Guinea during the Ebola outbreak and provided medical care on board the Aquarius, a search-and-rescue boat in the Mediterranean.

If his name sounds familiar, you may have caught one of the trillion sensationalistic new stories written about him after he contracted Ebola doing aid work in West Africa. Spencer fell ill shortly after his return to New York, entering Bellevue Hospital in October 2014. He needed 19 days to recover. For a lesser humanitarian, that experience might have spelled the end of his aid work. Not Spencer. After recovering from Ebola, he returned to an MSF treatment center in Guinea with a renewed sense of purpose. We caught up with the good doc at his family’s cabin in New Hampshire to discuss what the U.S. media got wrong about Ebola; how a single doctor, two nurses, and a midwife can triage a thousand sick people; and what he thinks is the most underrated country in Europe.

When someone learns that you work with Doctors Without Borders, what is the typical reaction?

“People are very, very curious. The next question is usually, ‘When was the last time you were abroad?’ or ‘Where did you go?’ People are interested because they associate Doctors Without Borders with these really challenging, high-intensity conflicts.”

So you find yourself getting cornered at parties a lot?

[Laughs] “Not really. I have a bunch of different lives, because I work with Doctors Without Borders four or five months a year and then I work in an emergency department in New York City the rest of the time. People are more interested in how I’m able to have two dream jobs instead of just one. But it’s always cool talking about our experience, especially working with staff on the ground.”

You mean the locals in the destinations where you’re dispatched for Doctors Without Borders?

“Yeah. A lot of people think, ‘Oh, you’ve got people trained from all over the world meeting up in this one place to do a mission or tackle some type of disease.’ But it’s overwhelmingly people from that country or region who have some training or are being trained by MSF. How do you get things from Amsterdam or Brussels to the middle of Burundi when there are no flights or there is ongoing civil conflict? We rely on people in-country to help us with cultural and logistical issues. Those people are invariably awesome—some of the best doctors I’ve ever met.”

You must be constantly surprised by the ingenuity of these physicians and nurses—how they make ends meet with such limited resources.

“It’s true from a nonmedical as well as a medical perspective. You say to a logistician, ‘Hey, I need a place to put 50 to 70 injured people using only what we have in the yard right now,’ and they’re like ‘OK, no problem, we got it.’ And sure enough, by the end of the day, there’s this amazing structure and you’re ready for whatever mass casualty comes in. Medically, it’s inspiring and motivating to work with people who approach medicine from the same textbooks as the colleagues I work with in the U.S. but have very limited resources. You have to rely on physical exam.

“You don’t need a stethoscope in the United States—it’s nice, because it makes you look like a doctor, but a chest X-ray or CAT scan is diagnostically better. That’s not true in a lot of places that MSF and I work. You’ve got your eyes, your experience, and maybe access to a couple of blood tests. When I was on the Aquarius in the Mediterranean, we had something to check blood sugar and something to check hemoglobin—and that was it. At Columbia, I have access to 24-hour MRI, ultrasound, neurosurgeons . . . all of these really fancy things. On the boat, it’s just you and what you’ve learned and what you’re able to talk about with your team. It’s super challenging but also super rewarding.”

Do you ever return to the U.S. after an MSF deployment, look around at all of the state-of-the-art equipment, and think “Nobody needs all this stuff”?[Laughs] “Look, some of the medical care we’re able to give here in the U.S.—cancer care and trauma care, in particular—is so advanced because it needs to be. There’s certainly a benefit to it. At the same time, I always say to my residents that the world isn’t all extracorporeal membrane-oxygenation fancy machines; there is a value to things we’ve overlooked for the sake of simplicity and speed. MSF has made me a better clinician because it has made me more balanced.”

OK, let’s step back in time. Did you play “doctor” a lot as a little kid?

[Laughs] “No, actually. I wanted to be a sharkologist. Then someone crashed all of my dreams and told me sharkologists did not exist, and I would have to be a marine biologist instead. They said I’d have to learn about, like, plankton and algae for years and I was like—nah, I just wanna be a sharkologist.” [Laughs]

Where’d you get the idea to become a doctor?

“When I was 10 or 11, I was looking at a jobs microfiche in social studies class, and I remember seeing that a cardiothoracic surgeon made, like, waaay more money than all of the other professions. It was like $180,000 or something. I was like, ‘Whoa! That seems like a lot of money. I’m 10, I don’t know what money is, but I want to do that.’ [Laughs] So from that moment on, I told everyone I was going to be a cardiothoracic surgeon. And that’s largely why I went to medical school. The job seemed important and meaningful, since everyone has a heart, but I also wanted to make a ton of money.”

But you later switched to emergency medicine, right?

“Right. I went to college, got my degree in European medieval history and the derivation of romance languages—because that prepares anyone for being a doctor [laughs]—and then I went to medical school. My plan at that time was still to become a cardiothoracic surgeon, but I took a trip to the Dominican Republic with the World Health Student Organization during my first year. That set me on a different path.”

How so?“I was there for a week and I remember being absolutely amazed at the stark contrast between what existed in the U.S. and what existed there. I saw one guy sitting in a bed with a wound covered in maggots and all of these other really unwell people. But they were, I dunno, just grateful for what very little our team and the doctors we were working with were able to provide. Seeing that inequality was quite profound.”

How did you get involved with Doctors Without Borders?

“When I finished medical school, I decided I was going to become an emergency medicine doctor because they have to work with all populations: You have to deliver a baby, you have to treat women and children, you have to care for trauma. I did my residency in Flushing, Queens. The majority of people I took care of were Chinese-speaking, but there were also Orthodox Jews and Greek grandpas and Russian women in their 20s. At the end of my residency, I applied for a fellowship in international emergency medicine at Columbia, where I am now, and part of that process involved spending around half of the two-year fellowship abroad.

“I did epidemiology, measuring human rights abuses and access to healthcare in Southern Burundi, Rwanda, and the Congo. That was the first time I’d worked in Africa and it really struck me. I worked alongside MSF on a couple of projects and really loved what they were doing. I support their neutrality and impartiality but also their focus on witnessing and giving people a voice. The humanitarian principle of not getting involved in the politics—we don’t care who shoots who, we take care of whoever is sick—I really appreciate that. Eventually I applied to MSF and I’ve done six different missions with them since 2014.”

Tell me about those missions.

“I was in Guinea a few times during Ebola in 2014 and 2015. I worked in Chad as an epidemiologist for hepatitis E. I worked in Burundi, in East Africa, in 2016, during the civil unrest. I was there just over three months, training local doctors how to respond to trauma and mass casualty, which basically involved relaying what would happen if someone throws a grenade into a market and you get 80 people that are all injured or maimed at once. How do you triage? How do you focus your resources on saving the most lives and the most limbs in the shortest period of time? At the end of the three months, it was pretty cool seeing how much people had learned and how much I had learned. Then most recently, I was on the Aquarius for three months as a medical doctor. I was the only physician, working with two amazing nurses and a midwife.”

Were there a lot of births on board?

“The midwife was there primarily to take care of women and sexual health issues, because we knew that would be a problem for the population making the voyage. We did have a surprise one day though: On one of the last rescues, we’re circling around the back of this little wooden boat and I did a double take because I saw a tiny pair of feet and a tiny head wrapped in a scarf. I asked the mom, ‘What is that?’ She took off the scarf and it’s her newborn baby that she’d just delivered minutes before; it was still attached by the umbilical cord! I stood there like, ‘Oh. My. Gosh. Nobody ever taught me in medical school how to get a woman attached by her umbilical cord to a newborn baby off of a dinghy and onto a rescue boat in the middle of the Mediterranean Sea.’ The search-and-rescue group was like, ‘What do we do?!’ and I’m like, ‘I don’t know! I’ve never dealt with this before.’ But we figured it out. We got her safely from one boat onto the other and then got her up to the clinic, where we delivered the placenta. That was a really cool experience and definitely something that tested my limits.”

When you’re making rounds to the migrant dinghies, pulling off people who look sick or weak, what happens after you treat them?

“Once people reach international waters, more than 12 nautical miles from Libya, they are in international space. If we rescue them, it’s not only personally or morally unacceptable to take them back to Libya, it’s against the law of refoulement—repatriating someone to a situation where they believe they are going to be at risk of persecution or torture. Nearly all of the people on the boats were in a really bad situation: tortured, abused, raped, beaten for ransom. Since we couldn’t take them back to Libya, they would be disembarked at the nearest safe port, which was invariably somewhere in Sicily or mainland Italy. Even though our rescue vessel was only 77 meters, we had 1,000 people on board and many of them were really, really sick—with sepsis, gunshot wounds, torture wounds. Our job was to find the very sickest people and make sure they got the right treatment.”

When you have 1,000 migrants on a rescue ship, and many haven’t eaten much in months, how do determine who is the sickest?

“We had to get creative. One of our best tricks was handing out food. We asked everyone to get in a big food-distribution line—forcing them to stand up, walk, and look us in the eyes. If you haven’t eaten a lot in the past six months and you don’t get up for food, there’s something wrong. So all of those people who don’t get up or try to get up but need assistance—that was the best way to triage. But you know, people wouldn’t complain. They just endured quietly and then you’d get them into the clinic and find this massive infected wound or abscess that’s making them a 103-degree fever or a heart rate of 140. It was crazy. The will to live is so much stronger than the body. One 16-year-old was 80 kilograms when he left home and he was 40 when we rescued him. Yet he refused to let people help him go up stairs or get dressed. He was so strong-willed and stubborn, he made it; a lot of other people in his situation wouldn’t have.”

Do you choose your assignments with MSF or do they choose for you?

“When you first sign up, they send you where there’s a need. If they suggest a place, it’s best form to accept that unless you have a serious safety concern. But normally you’d have discussed all those things beforehand—your tolerance for risk, your language skills, your previous experience. After that first assignment, you have more leeway to make shorter missions or to go to different places. MSF is really good at keeping people within the organization, although it’s hard for doctors to continue with them since we have such high debt. When you’re doing a mission, you don’t make anything close to what you’d make running a cath lab or working in an emergency department in the United States.”

Is there anywhere you aren’t willing to go?

“No, there isn’t. But for some people there are and MSF is very sensitive to that. You can be in the middle of a project with a billion patients and say ‘I don’t feel comfortable with this, I need to leave,’ and they’ll respect that. They’re very focused on security because they’re in such insecure places. MSF is there when no one else is. They feel that everyone, even in the middle of a civil war, deserves access to high-quality healthcare. And they’ll negotiate with both sides. They’ll say to the Taliban or local armed groups, ‘Listen, we’ll treat you, we’ll treat everyone, but this is how it is going to work.’ ”

When you’re on a mission, what are the food and accommodations like?

“It’s different every time. Places we sleep are generally nice; sometimes you have a roommate, but if you’re there for a longer period of time, you usually have your own space. The logisticians do a good job making sure we have running water and Wi-Fi or cell phones with a 3G or 4G connection. There are guards to make sure that everything stays secure. People come and cook meals for us while we’re at the hospital—that’s pretty nice! The most restrictive accommodations were in Burundi. For a month, we weren’t allowed to go anywhere but our house and the hospital, which were 100 meters from each other.”

What keeps you from going stir-crazy when you’re in lockdown like that?

“Exercise is really big in MSF. And they do a good job taking care of provisions—if you need a beer or food. After a month, we reassessed the [security] situation in Burundi and were able to go out and see the city—get an ice cream or grab a beer and see the local Burundians playing pool.”

What was life on the Aquarius like?

“I wasn’t sure what to expect, but the cabins were really nice! We had a Ghanaian chef and a chef from Indonesia who made wonderful dishes three times a day. It was pure luxury. And when you get off the boat, you disembark in Salerno, where you can go to a craft beer bar and have the best mozzarella di bufula pizza of your life. It’s a crazy contrast: You go from trying to treat 1,000 people on a rescue boat to having this incredible granita and brioche in Sicily or an aperol spritz in Brindisi.”

With so many humanitarian crises happening all over the world, how do you not get overwhelmed? You lose people sometimes. You lose children. How do you cope with that?

“It’s different for every assignment. Working on Ebola and seeing people die a lot, people that seemed well and then an hour later were dead, was always really sad and stressful. It’s hard to be that close to misery and part of a humanitarian crisis that the international community wasn’t responding to with enough strength. Same thing on the boat. No matter how happy we were that all of these people weren’t going to drown in the Mediterranean, things are still going to be really difficult for them going forward in Italy.”

Right, because they’re still refugees in limbo.

“Yeah, and with all the language around migration in the E.U. and globally, we don’t know what will happen to people. It’s really difficult. But I try to train on the positive aspects of [the job], like knowing that every person we pull out of a lifeboat is one less person who absolutely would have drowned otherwise. I focus on the meaningful interactions I’ve had with people—listening to their stories, providing advice, handing them drums and letting them sing for the first time in months. There have been humanitarian crises since time immemorial, but the number of people on the move right now is the highest it has been since World War II.

“It’s really sad, but there are reasons for optimism and hope. At our core, people can be really good and are really good—we just need to keep reminding each other of that, despite all the craziness happening around us. And honestly, I don’t care how anti-immigration or nationalistic or racist you are: If you can look into someone’s eyes who is sitting helplessly on an unseaworthy dinghy and not feel their pain and vulnerability, we’ve lost something as humanity. We may disagree on what should have been done before or what should be done after, but I hope there is no one in existence who truly thinks that person should be left to drown.”

I read the story you wrote in The New England Journal of Medicine titled “Having and Fighting Ebola — Public Health Lessons from a Clinician Turned Patient.” In the piece, which you published after recovering from Ebola, you note how the New York media was running around crazy like, “OMG, did he ride the subway?! What restaurants did he eat at?! Did he go bowling?!” Meanwhile, there is this massive Ebola epidemic unfolding in West Africa and the media hardly bats an eyelash. This must be a constant source of frustration for you when doing aid work.

“I was super frustrated with that and continue to be. In the speech I gave when I left the hospital, I asked the media to stop focusing on me and start covering the thousands and thousands of other people whose lives and families are being torn apart by a virus that could have been contained and controlled a lot earlier. There is harsh rhetoric in the media in response to illness. I try to use my experience as an individual to talk about how we can improve health in developing countries, but I also want to focus on the bigger issues—like the fact that people are drowning at sea on Europe’s doorstep. I don’t want the discussion being clouded by my past illness. When I returned to Guinea [after recovering from Ebola], I didn’t do any interviews and MSF didn’t publicize my return. We treated it like work.”

It’s incredible you went back. Some people would go through an ordeal like that and say, “You know what, I’m just gonna move to the country now and open a nice general practice.” What made you return?

“I’m a doctor; I have experience working in really difficult situations—if not me, then who? That’s why I went the first time. Before I left, I sat with my wife and said, ‘Look, there’s a possibility I could get sick.’ We talked about it and made an action plan. When I got sick, we dealt with it. [Contracting Ebola] made me realize just how big of a problem it still is and that we needed more people to respond to it. So I sat down with my wife again and said, ‘I think I need to go back.’ I had worked in an Ebola treatment center for seven weeks and understood what happened within those walls. I knew my voice and my experience would allow me to be able to talk about the epidemic as a whole. MSF was really supportive, and so was my wife and family. They knew how much it meant to me.”

On a lighter note, when you and your wife take a real vacation, where do you like to go?

“My favorite place in the world is this cabin my wife’s grandparents bought on a lake in New Hampshire. It’s surrounded by this unending line of pine trees and the cabin itself is lined with dime-store novels from the 1950s. I come up here as much as I can to kayak and think and write and spend time with family. But our coolest trip was probably our honeymoon: We traveled from Sarajevo to Crete—through Croatia, Montenegro, Albania, and Greece. It was unbelievable. We were especially blown away by how incredible Albania was. It’s just as beautiful as Croatia and Montenegro, yet so much cheaper and less touristy. I saw one of the best beaches of my life there. We visited in September but there were no tourists. The only thing on any of the sun beds were goats! [Laughs] So you had to, like, push a goat off to get under an umbrella. It was just beautiful, the people were amazing, the food was. . . .”[sighs happily]

Goats on sun beds—I’m sold.

“We went to a restaurant next door to the beach and we ordered octopus. And you see a guy literally going out into the sea with a spear to get an octopus! We had this fantastic meal, wine, beer, beautiful salad, and it was, like, 15 euros for both of us. Tell your readers: Tirana down to Saranda in Albania. It’s awesome.”